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NURAND3 > Physical assessment > Flashcards

Physical assessment Flashcards

1
Q

Name Location: Aortic Area

A

Second intercostal space, right sternal boarder

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2
Q

Name Location: Pulmonic area

A

Second intercostal space, left sternal boarder

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3
Q

Name Location: Er’b Point

A

Left sternal boarder, third intercostal space

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4
Q

Name Location: Tricuspid area

A

Left sternal Boarder, fourth intercostal space

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5
Q

Name Location: Mitral area (PMI/Apical) also Apical pulse

A

Fifth intercostal space, mid clavicular

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6
Q

Heart sounds: S3?

A

Ventricular gallop and heard just after S2 at the apex or at the lower, left sternal boarder. (Almost always says heart failure in people over 40)

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7
Q

Heart sounds: S4?

A

Atrial gallop and heard before S1, at the apex or at the lower left sternal boarder and occurs when blood flow from atrial contraction meets increased resistance in ventricle (Usually heard in hypertensive patient) Left side heart has trouble (resistance)

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8
Q

Normal range: apical pulse

A

60-100 BPM

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9
Q

Normal range: Respiratory rate

A

12-20 RPM

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10
Q

Normal range: systolic BP

A

less than 120

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11
Q

Normal range: Diastolic BP

A

less than 80

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12
Q

What happens when I hear the S1?

A

Mitral and Tricuspid valves are closing

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13
Q

What happens when I hear S2?

A

Aortic and Pulmonic valve are closing

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14
Q

Lung Sounds: Crackles/rales?

A

Sudden opening and closing of airways, soft high pitched scratching sounds.

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15
Q

Lung Sounds: Wheezes

A

Air through narrowed airways, louder on expiration, high pitched and musical.

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16
Q

Lung Sounds: Rhonchi

A

Fluid blocked airways, Low pitched rumbling

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17
Q

Vesicular breath sounds?

A

Normal breath sounds.

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18
Q

Stridor?

A

Abnormal breath sounds an inspiratory wheeze heard in the neck due to partial obstruction.

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19
Q

Bronchovesticular breath sounds?

A

Heard over mainstream bronchi below clavicles adjacent to sternum.

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20
Q

Bronchial breath sounds?

A

Heard over the trachea above the sternal notch.

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21
Q

(+) JVD indicates?

A

Usually indicates R-sided heart failure. The Jugular will be observed in the up position filled with blood with multiple pulsations not equal to the heart rate.

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22
Q

Breath sounds Anterior

A

Breath sounds Posterior

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23
Q

S1 Is heard best over which part of the heart?

A

The first heart sound heard best over the mitral and tricuspid areas

24
Q

S1 Heart sound is also called?

A

Atrioventricular heart sound

25
Q

S2 is also called?

A

Semilunar heart sounds

26
Q

Neurologic Motor responses include?

A

Eyes open, Follows command to stick out tongue, squeeze fingers, move extremities

27
Q

Pulse Sites

A
28
Q

How do you assess for pitting edema?

A

Press finger firmly for 5 seconds in skin on top of foot or inner ankle bone.

29
Q

Equipment

IV, Fluids, Piggybacks

What are we checking when entering the room?

A

Are the fluids what you got rapport on? When does it expire? how long has it been running?

Does the tubing have a sticker when it needs changing? Rate and is this correct? What type of device? Saline lock?

Piggy back? What is hanging? when is it due to expire? Is it running? When does it finish? Antibiotics? When does the tubing expire? When did it start? Does it require peak and trough levels?

30
Q

Oxygen therapy

When entering the room we are checking?

A

What delivery system are they on? (e.g. Nasal canal, High flow, mask, by-pap, c-pap) is this correct for the patient? How many Liters are they on? is it correct?

31
Q

NG Tube

When entering the room what are we Checking?

A

Why do they have it in? is it set right? Is the system working correctly, Is the canister full? Empty it…Note color, consistency, volume.

32
Q

Indwelling catheter

When Entering the room what are we checking for?

A

Do you see Indwelling catheter drainage bag? Full? then empty it and note volume, color, consistency. What does the catheter look like?

33
Q

What signs should be posted for Patient Safety?

When do we assess?

A

Fall Risk? Did they fall at home? Is there a sign above the bed indicating? Are they on fall precautions? Do they have a bed alarm? Is the alarm set?

Is the patient on anticoagulant therapy? Why are they on the therapy? Is there a sign for Bleeding precautions? Investigate if not posted.

Can they have Blood pressure taken on both arms? if not why? is there a sign?

Does it look like they are in respiratory distress?

34
Q

Entering the room we start assessing, What do we observe about the patient?

A

Look at the patient skin, Note the color compare with lower extremities (are they the same color), Look at facial symmetry, Do they make eye contact? What type of facial expression do they have?

35
Q

Pain assessment

PQRST

What does the “P” stand for?

A

Provocation and Palliation- (Press on it, Pleased with it)- What causes it? What makes it better? What makes it worse?

36
Q

Pain assessment

PQRST

“Q” stands for?

A

Quality and Quantity- How does it feel, look, sound? How much of it is there?

37
Q

Pain assessment

PQRST

“R” stands for?

A

Region and Radiation- Where is it, does it spread?

38
Q

Pain assessment

PQRST

“S” stands for?

A

Severity and Scale- Does it interfere with activities?, how would you rate the severity on scale 0-10?

39
Q

Pain assessment

PQRST

“T” stands for?

A

Timing and Type of onset- When did it begin? How often does it occur? Is it sudden or gradual?

40
Q

Pain Assessment

OLDCART

“O” Stands for?

A

Onset of pain

41
Q

Pain Assessment

OLDCART

“L” stands for?

A

Location

42
Q

Pain Assessment

OLDCART

“D” stands for?

A

Duration

43
Q

Pain Assessment

OLDCART

“C” stands for?

A

Characteristics (Sharp, dull, throbbing, electric shock, tingling, pins and needles)

44
Q

Pain Assessment

OLDCART

“A” stands for?

A

Aggravating Factors (Walking, Sitting, lying down, other movements)

45
Q

Pain Assessment

OLDCART

“R” stands for?

A

Relieving Factors? (Medication, cold/warm applications, positioning)

46
Q

Pain Assessment

OLDCART

“T” stands for?

A

Time Factor (Time of day or night at which pain is worse or better)

Treatment- (What are you using and doing and taking to minimize the pain)

47
Q

How do you assess the Head, What question do you ask?

A

Does the patient look well groomed? Poor Hygiene? Access to healthcare? Hair matted or dirty?

Eye color? Are they wearing glasses or contact lenses? Do the eyes open appropriately?

The Scalp- Feel for any bumps, or anything out of the ordinary, Check for lice and if + set precautions.

Ears- Look behind ear for skin breakdown, Ask if they wear hearing aids, are the ears clean, Walk over to other ear to examine.

Eyes- Are they tracking you? Is there any drainage? Check pupils (LIGHTS DIM), Check accommodation (Bring object close to eye), Is the sclera white? Red?

Skin- Note color, and wounds,

Nares- Check for sores, check both sides, Extended O2 therapy then check for humidifier.

Mouth- Open mouth, Do they have teeth, cavities? Dentures? Membrane and gums pink and moist? Have them stick out tongue (observe tonsils, uvula for enlargement or anything out of ordinary) Is the tongue white? pink?

48
Q

How to assess the Neck?

A

Check the Jaw, can they open mouth, Check lymph nodes in neck and face, Check carotid pulses 1 at a time (Have patient hold breath for a second) Listen over carotid for bruit.

49
Q

What to assess with the arm? and Hand?

A

Compare one side to the other, Check the skin for color and size, Check ROM, Raise arms, note discrepancies.

Hands- Check IV site and follow tube from hand to bag, check sticker for change time and date,

*Check for infiltration- When fluid escapes the vein and pools into the interstitial tissue: Signs include Edema, pain, coolness at site and check other hand to compare by touch and observing pain.*

Look at fingers and the skin, check capillary refill <3sec normal, Look at the nails, Strength-Have patient squeeze fingers (rate on scale 0-5), push and pull against my hands, Check sensation by having PT close eyes and describe where I poke.

50
Q

How to perform the cardiac Assessment?

A

Check leads and central lines and make notation, Use Stethoscope to listen and say out loud the points I’m at when assessing.

APEToMan

Does the patient have cardiac problems? Check for edema and Pitting (use scale to rate), Pulses-If doppler is used then mark with marker and note in the patient cart.

51
Q

Assessment of the Respiratory system includes

A

Is the patient Barrel chested? Chest rising in symmetry? How are they breathing? Any retractions? Tugging, working hard? Using accessory muscles?

Bring HOB to 45 degrees At this time check for *JVD*

Assess Anterior breath sounds in all 5x2 locations in zigzag formation.

Assess Posterior breathe sounds- Have patient lean forward, Also assess skin integrity and breakdown. Then assess sounds in Zigzag formation. Listening for any adventitious sounds.

Bring HOB Down

52
Q

Assessment of the Abdominal Region includes?

A

Look at abdomen and not if round, distended, any ecchymosis, Check fold of skin, what does the skin look like? note all, check skin turgor.

Listen to Bowel sounds in all 4 quadrants Normal-5-30 minute Hypo- <5 Hyper >20

Palpation- Gently feel, and assess for pain, mass, is the abdomen soft? is the pt comfortable when touch. Palpate the Bladder (Be careful)

Questions- Last bowel movement, what did it look like, Is that normal for you? and Last Void? Color, painful, difficult, and amount.

53
Q

Assessment of the lower extremities?

A

Observe the color, for edema (pitting), check and rate pluses, compare sides, check for skin breakdown, Look at feet and compare size of toes, check capillary refill

Assess ROM and strength- push pull, can they bend the knees? Check sensations, and assess any wounds

54
Q

Assessment of the perineum Area?

A

Gel-in and Don gloves

Explain to the patient what you will be doing at this time, and you will be touch them now

Check the perineum for any lesions, discharge, check color and for skin breakdown, clean if necessary, check foley at this time if the patient has one, and Check anal region, skin break down, hemorrhoids, fissures.

Remove gloves and gel-in

55
Q

How do I finish up the Physical assessment?

A

Place patient in desired position, lower the bed, side rails up, call light in reach, if they need anything, or if they have any questions.

56
Q

How to grade pulses using the scale 0-4

?

A

NURAND3 (6 decks)

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